State: Contact Person: Address: City: State: Zip Code: Phone: Fax: Email: Quality Management Plan A.1. Is a comprehensive HIV-specific, statewide quality management plan in place with clear definitions of leadership, Part B roles, resources and accountability? Part B program has no or minimal written quality plan in place; if any in existence, written plan does not reflect current day-to-day operations. Part B program has only loosely outlined a quality management plan; written plan reflects only in part current day-to-day operations. A written statewide quality management plan is developed describing the quality infrastructure, frequency of meetings, indication of leadership and objectives; the quality plan is shared with staff; the quality plan is reviewed and revised at least annually; some areas of detail and integration are not present. A comprehensive and detailed HIV-specific, statewide quality management plan is developed/refined, with a clear indication of responsibilities and accountability across DOH, quality committee infrastructure, outline of performance measurement strategies, and elaboration of processes for ongoing evaluation and assessment; engagement of other DOH department representatives is described; quality plan fits within the framework of other statewide QI/QA activities; staff and providers are aware of the plan and are involved in reviewing and updating the plan. A.2. Are appropriate performance and outcome measures selected, and methods outlined to collect and analyze statewide performance data? No appropriate performance or outcome measures are selected; methods to collect and analyze statewide performance data are not outlined. Only those indicators are selected that are minimally required; no process takes place to annually review and update indicators and its definitions; methods to collect data are not described. TA Guidelines Page 4.10 Developed by the National Quality Center (NQC)
Selection of indicators is based on results of past performance data and some input of Part B representatives; indicators include appropriate clinical or support service measures; indicators reflect accepted standards of care; indicator information is shared with DOH staff; processes are outlined to measure and analyze statewide performance data. Portfolio includes clinical and support service indicators with written indicator descriptions; measures are annually reviewed, prioritized and aligned with DOH quality goals; all indicators are operationally defined, and augmented with specific targets or target ranges, including desired health outcome; DOH performance measurement activities include partnering with other data sources such as Medicaid and Epidemiology data; Program Assessment Rating Tool (PART) measures and unmet need are integrated; statewide data collection plans are clearly outlined and strategies to analyze data are detailed. A.3. Does the work plan specify timelines and accountabilities for the implementation of the statewide quality of care program? No work plan is specified for the implementation of the statewide quality of care program. A work plan is only loosely outlined; no specific timelines for the implementation of the statewide quality of care program are established; no formal process to assign timelines and responsibilities; follow-up of quality issues only as needed. A written, annual work plan which outlines the implementation is in place; timetable is shared with appropriate DOH staff; updates in the work plan are discussed in quality committee(s); quality activities are planned before execution. A process to assign timelines and responsibilities for quality activities is in place and clearly described; annual plan for resources is established; DOH staff are aware of timelines and responsibilities; quality committees are routinely updated and consulted on the implementation of the statewide quality program. Organizational Infrastructure B.1. Does the Part B program have an organizational structure in place to oversee planning, assessment and communication about quality? No quality structure is in place to oversee planning, assessment and communication about quality. Only a loose quality structure is in place; a few DOH representatives are involved; knowledge of quality structure among staff is limited. TA Guidelines Page 4.11 Developed by the National Quality Center (NQC)
Senior DOH representative heads the HIV quality program; DOH representatives from some internal departments are represented in the HIV quality structure; findings and performance data results are shared; staff for the quality program is identified; resources for the quality program are made available. Senior DOH leaders actively support the program infrastructure and planned activities; key staff are identified and supported with adequate resources to initiate and sustain quality improvement activities at the DOH program as well as the provider level; Part B staff is routinely trained on quality improvement tools and methodologies; findings and performance data results are frequently shared internally and externally. B.2. Is a quality management committee with appropriate membership established to solicit quality priorities and recommendations for quality activities? No Part B quality management committee is established to solicit quality priorities and recommendations for quality activities. Quality meetings are held with only a few DOH representatives and/or provider representatives; ad hoc meetings are only used to discuss immediate issues. Quality committee is established that engages various representatives; routine quality committee meetings are held to solicit quality priorities and recommendations for quality activities; reporting of committee updates in place. Senior DOH leader, key Part B providers and consumer representatives are actively involved in quality committee(s) to establish priorities and solicit recommendations for current and future quality activities; membership is reviewed and updated annually; HIV quality meetings include written minutes and reporting mechanisms. B.3. Does the Part B quality program involve providers, consumers and representatives, such as ADAP, Medicaid, Epidemiology and from other Ryan White Program Parts? Part B quality program does not involve providers, consumers and representatives, such as ADAP, Medicaid Epidemiology and from other Ryan White Program Parts. Part B quality program includes only internal DOH staff, with limited input from other departments; neither Part B providers nor consumers are involved. Representatives from a few DOH departments, Part B providers and at least one consumer TA Guidelines Page 4.12 Developed by the National Quality Center (NQC)
representative are participating in quality committee meetings; other Ryan White Parts are involved. Representatives from all appropriate internal DOH offices, including ADAP, Medicaid, and Epidemiology; Part B providers and consumers are actively engaged in the statewide quality of care; representatives from other Ryan White Parts are structurally integrated in the quality program. B.4. Are processes established to evaluate, assess and follow up on HIV quality findings and data being used to identify gaps? Processes are not established to evaluate, assess and follow up on HIV quality findings. No processes are established to evaluate the HIV quality program; quality infrastructure and its activities are reviewed only if necessary; when establishing/updating the annual work plan, past performance is not considered; quality of care program does not learn from past successes and failures. Review process is in place to evaluate the Part B quality infrastructure, and assess the performance data; findings are generated for follow up and used to plan ahead; summary of findings are documented. Process to annually assess effectiveness of HIV quality program; data findings are used to identify gaps in care and service delivery; DOH staff is actively involved; assessments and follow ups are documented; HIV leadership is well aware and involved in evaluation of HIV quality program; findings and past performance scores are used to facilitate and shape Part B quality program. Implementation of Quality Plan and Capacity Building C.1. Are appropriate performance data collected to assess the quality of HIV care and services statewide? No performance data are collected to assess the quality of HIV care and services statewide. Basic performance measurement systems are in place; only utilization data are collected; no process established to share data or only used for punitive purposes; data are not collected statewide. A system to measure key quality aspects among Part B providers is established; data are TA Guidelines Page 4.13 Developed by the National Quality Center (NQC)
collected, analyzed and routinely disseminated to providers; data are collected from most providers around the state. The quality, including clinical and support services across the state, is measured by selected process and include outcome measures; organizational assessments of Part B provider quality infrastructures are conducted; results and findings are routinely shared with providers to inform and foster quality improvement activities; data are collected from the entire state. C. 2. Does the Part B quality program conduct quality improvement projects to improve DOH systems and/or quality of care issues? The Part B quality program does not conduct quality improvement projects to improve DOH systems and/or quality of care issues. Quality improvement activities focus on individual cases or incidents only; projects are primarily used for inspection; selection of quality activities is done by single person. A few DOH staff members have input in the selection of quality projects; quality improvement activities focus on issues related to structures and processes only; at least one quality project was conducted in the last 12 months to improve DOH systems and/or quality of care issues; DOH internal Part B,quality improvement activities are tracked. Structured process of selection and prioritization of quality projects is in place; quality improvement projects are informed by the data and are outcome related; DOH staff across several departments is involved in quality improvement projects; findings are routinely shared with entire DOH staff, presented to the quality committee, and used to inform subsequent projects. TA Guidelines Page 4.14 Developed by the National Quality Center (NQC)
C.3. Does HIV quality program offer QI training and technical assistance on quality improvement to Part B providers? The quality program does not offer QI training and/or technical assistance on quality improvement to Part B providers. No structured process in place to train Part B providers on quality improvement; limited technical assistance resources available for Part B providers to build capacity for quality improvement. Capacity to train Part B providers and provide technical assistance on quality improvement is available; process in place to triage TA requests from individual providers; some resources are available and mostly used in response to TA requests. A quality workshop program is established to routinely train clinical and service providers on quality improvement priorities, tools and methodologies; an annual training schedule is developed with quality topics based on needs assessment including input by providers; trainings are well attended and evaluations are routinely kept and analyzed and used to improve future training; technical assistance is provided to clinical and service providers through on-site visits by quality experts. TA Guidelines Page 4.15 Developed by the National Quality Center (NQC)